Author Topic: What comes after the ACA?  (Read 819457 times)

Exflyboy

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Re: What comes after the ACA?
« Reply #4950 on: November 12, 2018, 12:00:43 PM »
At least the ACA is probably safe for the next 3 years for better or worse.

SugarMountain

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Re: What comes after the ACA?
« Reply #4951 on: November 12, 2018, 03:06:29 PM »
At least the ACA is probably safe for the next 3 years for better or worse.

I agree, although there are two things that concern me.  One is the ongoing lawsuit that I believe 20 states have joined.  The other is with the mandate gone costs are going to continue to spiral up as healthy young people have very little incentive to carry insurance, they can just wait until they get sick and then get insurance.  That's not without risk, but if say they blow out their knee in July, they can defer surgery until the following January and the insurer will be forced to cover the "pre-existing condition". 

There were 3 legs to the stool:
1) Guaranteed coverage, i.e. no denying based on pre-existing conditions.
2) Mandate that everyone get insurance.
3) Financial assistance for #2 for those who can't afford it.

Take out any of the 3 and the whole thing is at risk for falling apart.  They've successfully removed #2, which is going to make #1 more expensive since the insured will tend to be sicker and older. (This will also cause #3 to be more expensive for the government since the subsidies are based on the 2nd cheapest silver plan in a state.)

protostache

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Re: What comes after the ACA?
« Reply #4952 on: November 12, 2018, 04:40:09 PM »
This part boggles my mind. How much time does it actually take to send a bill to an insurance company, and then bill the patient for any remainder? If the billing department gets 30% and the doctor gets 5%, and the billing piece takes less than six times as long as the actual patient visit, wouldn't a doctor be better off becoming their own billing department and reducing their patient load as needed to keep a reasonable schedule?

I have no idea what's normal for smaller offices, but my wife is in a major university hospital antepartum right now and I'm seeing professional services claims in Aetna's system on about a three day lag.

seattlecyclone

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Re: What comes after the ACA?
« Reply #4953 on: November 12, 2018, 04:50:11 PM »
This part boggles my mind. How much time does it actually take to send a bill to an insurance company, and then bill the patient for any remainder? If the billing department gets 30% and the doctor gets 5%, and the billing piece takes less than six times as long as the actual patient visit, wouldn't a doctor be better off becoming their own billing department and reducing their patient load as needed to keep a reasonable schedule?

I have no idea what's normal for smaller offices, but my wife is in a major university hospital antepartum right now and I'm seeing professional services claims in Aetna's system on about a three day lag.

Is this three days of a person working full-time hours on just that claim, or merely that they spend a few minutes to file the paperwork and then wait three days?

Paul der Krake

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Re: What comes after the ACA?
« Reply #4954 on: November 12, 2018, 05:45:47 PM »
This part boggles my mind. How much time does it actually take to send a bill to an insurance company, and then bill the patient for any remainder? If the billing department gets 30% and the doctor gets 5%, and the billing piece takes less than six times as long as the actual patient visit, wouldn't a doctor be better off becoming their own billing department and reducing their patient load as needed to keep a reasonable schedule?

I have no idea what's normal for smaller offices, but my wife is in a major university hospital antepartum right now and I'm seeing professional services claims in Aetna's system on about a three day lag.

Is this three days of a person working full-time hours on just that claim, or merely that they spend a few minutes to file the paperwork and then wait three days?
Unless they employed felons paid at $1/hour, there's no way it could ever work that way.

Claim processing is just an eventually consistent system with shit SLAs.

DreamFIRE

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Re: What comes after the ACA?
« Reply #4955 on: November 12, 2018, 06:40:26 PM »
At least the ACA is probably safe for the next 3 years for better or worse.

You can expect key provisions of the ACA (pre-existing conditions, subsidies, and more) or the whole thing to be overturned any day now:

https://forum.mrmoneymustache.com/welcome-to-the-forum/what-comes-after-the-aca/msg2197540/#msg2197540

There will certainly be an appeal in that case.  Who knows how long it will drag out - probably not 3 years, though.

pecunia

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Re: What comes after the ACA?
« Reply #4956 on: November 12, 2018, 07:28:32 PM »
At least the ACA is probably safe for the next 3 years for better or worse.

You can expect key provisions of the ACA (pre-existing conditions, subsidies, and more) or the whole thing to be overturned any day now:

https://forum.mrmoneymustache.com/welcome-to-the-forum/what-comes-after-the-aca/msg2197540/#msg2197540

There will certainly be an appeal in that case.  Who knows how long it will drag out - probably not 3 years, though.

If those elephant guys were to overturn this thing now,they would assuredly suffer for this later.  They saw the backlash the last time they tried to do this.  This is the kind of issue that does more than kill people in some far off country like one of their wars.  This is an issue that can kill grandma or cute little baby Nell.

Mr. Green

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Re: What comes after the ACA?
« Reply #4957 on: November 12, 2018, 09:24:47 PM »
At least the ACA is probably safe for the next 3 years for better or worse.

You can expect key provisions of the ACA (pre-existing conditions, subsidies, and more) or the whole thing to be overturned any day now:

https://forum.mrmoneymustache.com/welcome-to-the-forum/what-comes-after-the-aca/msg2197540/#msg2197540

There will certainly be an appeal in that case.  Who knows how long it will drag out - probably not 3 years, though.
There would certainly be an appeal. There's already a counter suit by a handful of states. You can be assured that if the current lawsuit strikes down part or all of the law, the countersuit will seek an injunction until that can be settled as well. It will take some time for the whole thing to play out.

freya

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Re: What comes after the ACA?
« Reply #4958 on: November 13, 2018, 06:16:01 AM »
- Billing:  Outsourced, which is usual practice.  They take 30% right off the top.

This part boggles my mind. How much time does it actually take to send a bill to an insurance company, and then bill the patient for any remainder? If the billing department gets 30% and the doctor gets 5%, and the billing piece takes less than six times as long as the actual patient visit, wouldn't a doctor be better off becoming their own billing department and reducing their patient load as needed to keep a reasonable schedule?

It's as quick as you suggest when it's Medicare or Medicaid, but with private insurance it's an absolute nightmare.  Filing the initial claim is easy, but that just starts a long cycle of denial, phone call to company (=hours on hold), providing additional documentation, refiling, more denial, etc etc.  Some insurance companies routinely deny everything the first time around.  And of course each one has its unique and ever-changing requirements.  It's too much for a nonspecialist to manage, regardless of group size.

This is why if we went single payer with Medicare as the national health plan, to which you pay the same premiums you pay now for private insurance, we would instantly save something like $700 billion nationally in health care costs.   Private insurance, it turns out, is a very expensive hobby.   This is in addition to what we might be able to accomplish by fixing the "corporate culture" that medicine has become, which along with perverse incentives in the coding system drives the excessively procedure-oriented care.  A single payer system would make this easier to address, too.

BeanCounter

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Re: What comes after the ACA?
« Reply #4959 on: November 13, 2018, 06:50:13 AM »

This is why if we went single payer with Medicare as the national health plan, to which you pay the same premiums you pay now for private insurance, we would instantly save something like $700 billion nationally in health care costs.   Private insurance, it turns out, is a very expensive hobby.   This is in addition to what we might be able to accomplish by fixing the "corporate culture" that medicine has become, which along with perverse incentives in the coding system drives the excessively procedure-oriented care.  A single payer system would make this easier to address, too.
I can say with 100% certainty from my experience working for one of the largest payors and then a large "non profit" health system that this is TRUE. Another thing that sucks up a lot of time and money is all the network negotiations between payor and provider. And a good chunk of the insured's premium goes to pay for the "network". The whole system is ridiculous.
It pains me that we can't as a country figure out how to just open up Medicare for everyone.

JenniiF

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Re: What comes after the ACA?
« Reply #4960 on: November 13, 2018, 07:38:30 AM »
I think one of the biggest issues with healthcare is the transparency. Why in the world do we not know how much we're going to pay for services before we go in? Most people don't realize just how drastically different prices can be from location to location. Granted, it's difficult for the hospital or medical facilities to know how much individuals are going to pay, because each insurance carrier is contracted at different prices, but we should at least get the cash prices posted somewhere.

I mean you can get a foot surgery for $15,000 at one location and $1,500 at another. Same procedure, no significant different in quality, and vastly different prices. The healthcare system is the only one where the difference in price can be multiples of 10 without a significant difference in price.

We need more resources to be able to price shop for our care, and more people willing to do their homework before they go in for a medical services. GoodRx and Healthcare Bluebook are two good options to start being smarter healthcare consumers, but we need more people willing to use them.

rantk81

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Re: What comes after the ACA?
« Reply #4961 on: November 13, 2018, 07:53:00 AM »
I'd like to know how a generic blood pressure medicine, 90 day supply, can have a Cash price of $222.19, but will only cost $6.85 after insurance negotiated discount, and would cost $10.26 if you bring in a printed GoodRX coupon.

How can the "market" for something have more than a 32X variance in price, depending on how you are billed for it?

BeanCounter

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Re: What comes after the ACA?
« Reply #4962 on: November 13, 2018, 08:43:39 AM »
I think one of the biggest issues with healthcare is the transparency. Why in the world do we not know how much we're going to pay for services before we go in? Most people don't realize just how drastically different prices can be from location to location. Granted, it's difficult for the hospital or medical facilities to know how much individuals are going to pay, because each insurance carrier is contracted at different prices, but we should at least get the cash prices posted somewhere.

I mean you can get a foot surgery for $15,000 at one location and $1,500 at another. Same procedure, no significant different in quality, and vastly different prices. The healthcare system is the only one where the difference in price can be multiples of 10 without a significant difference in price.

We need more resources to be able to price shop for our care, and more people willing to do their homework before they go in for a medical services. GoodRx and Healthcare Bluebook are two good options to start being smarter healthcare consumers, but we need more people willing to use them.
Totally agree. But with most services having the "cash price" or the charge master won't help because it totally depends who your insurer is and what their negotiated rate is and other than when you get your EOB that information is treated as a top secret agreement.
We ran into this situation in my own house. DH needed physical therapy. Being a good spouse he went to our family doctor to get the referral and went to MY EMPLOYER to get the PT. Because of who his insurer is through his work, we received a bill for a little over $1,500 for six sessions of PT. Because of what I do I knew that this was a ridiculous amount for outpatient PT. I called our rev cycle team. It seems that our contract with Anthem allows facility charges for outpatient PT. JUST BECAUSE THE SERVICE IS PROVIDED AT THE HOSPITAL PT gym. Mind you, there is no other place to have PT with the health system. This is something that we would not have had any way to know ahead of time. So we paid the bill and moved on. A year later DH needs some additional PT, this time I tell him to go to a free standing PT that is NOT affiliated with my employer. Total bill for six sessions from other PT provider- $300. That's a difference of $1,200 FOR THE EXACT SAME SERVICE.
TELL ME WHY THIS IS OK????

protostache

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Re: What comes after the ACA?
« Reply #4963 on: November 13, 2018, 08:49:20 AM »

This is why if we went single payer with Medicare as the national health plan, to which you pay the same premiums you pay now for private insurance, we would instantly save something like $700 billion nationally in health care costs.   Private insurance, it turns out, is a very expensive hobby.   This is in addition to what we might be able to accomplish by fixing the "corporate culture" that medicine has become, which along with perverse incentives in the coding system drives the excessively procedure-oriented care.  A single payer system would make this easier to address, too.
I can say with 100% certainty from my experience working for one of the largest payors and then a large "non profit" health system that this is TRUE. Another thing that sucks up a lot of time and money is all the network negotiations between payor and provider. And a good chunk of the insured's premium goes to pay for the "network". The whole system is ridiculous.
It pains me that we can't as a country figure out how to just open up Medicare for everyone.

We can make it happen. Right now thereís a very vocal minority of voters who donít want the ďwrongĒ sort of people to have access to health care services and that minority happens to control the Senate.  We need to work very hard over the next two years to regain control from this minority and, simultaneously, work out how we are going to handle the issues that keep coming up in this thread. I am confident it can be done, and done quickly. There is broad support, across party lines, for some sort of universal health care program. The details matter, but first we have to get past the minority that refuses to even discuss anything but actively tearing down the progress weíve made.

GettingClose

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Re: What comes after the ACA?
« Reply #4964 on: November 13, 2018, 10:37:39 AM »
Quote
Right now thereís a very vocal minority of voters who donít want the ďwrongĒ sort of people to have access to health care services and that minority happens to control the Senate. 

And are represented in the House by at least one guy from Tennessee who got 66% of the vote:

https://eu.tennessean.com/story/news/politics/2018/09/21/mark-green-government-god-health-care-marsha-blackburn/1367905002/

Quote
Government has stepped in, at least in this country, and done all the work for the church. So the person whoís in need goes ó they look to the government for the answer, not God. And I think, in that way, government has done an injustice thatís even bigger than just the entitlement ó creation of an entitlement welfare state

DaMa

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Re: What comes after the ACA?
« Reply #4965 on: November 13, 2018, 11:08:50 AM »

This is why if we went single payer with Medicare as the national health plan, to which you pay the same premiums you pay now for private insurance, we would instantly save something like $700 billion nationally in health care costs.   Private insurance, it turns out, is a very expensive hobby.   This is in addition to what we might be able to accomplish by fixing the "corporate culture" that medicine has become, which along with perverse incentives in the coding system drives the excessively procedure-oriented care.  A single payer system would make this easier to address, too.
I can say with 100% certainty from my experience working for one of the largest payors and then a large "non profit" health system that this is TRUE. Another thing that sucks up a lot of time and money is all the network negotiations between payor and provider. And a good chunk of the insured's premium goes to pay for the "network". The whole system is ridiculous.
It pains me that we can't as a country figure out how to just open up Medicare for everyone.

+1  I spent over 20 years working in the finance areas for a few major health insurance companies.  This is TRUE.  I've been a proponent of single payer for most of those years, and it would have put me out of a job.  If that's not honest, what is? 

One of the arguments against single payer that I hear is that government reimbursement is too low.  Well all the companies I worked for paid only slightly more than Medicare (if any) on most procedures.  And that wasn't worth the extra hassles.  If you take 30% off the top, then it's significantly less.

I've found it very interesting that doctors (in general) were against national healthcare in the 90's when Clinton tried, but are for it now.  The ones I have talked to all say it's, because of all the hassles of working with insurance companies.  Billing, pre-approvals, clinical guidelines, formularies, etc.  They all felt that the reduction in overhead would more than make up for lower payments.



BeanCounter

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Re: What comes after the ACA?
« Reply #4966 on: November 13, 2018, 12:04:00 PM »

This is why if we went single payer with Medicare as the national health plan, to which you pay the same premiums you pay now for private insurance, we would instantly save something like $700 billion nationally in health care costs.   Private insurance, it turns out, is a very expensive hobby.   This is in addition to what we might be able to accomplish by fixing the "corporate culture" that medicine has become, which along with perverse incentives in the coding system drives the excessively procedure-oriented care.  A single payer system would make this easier to address, too.
I can say with 100% certainty from my experience working for one of the largest payors and then a large "non profit" health system that this is TRUE. Another thing that sucks up a lot of time and money is all the network negotiations between payor and provider. And a good chunk of the insured's premium goes to pay for the "network". The whole system is ridiculous.
It pains me that we can't as a country figure out how to just open up Medicare for everyone.

+1  I spent over 20 years working in the finance areas for a few major health insurance companies.  This is TRUE.  I've been a proponent of single payer for most of those years, and it would have put me out of a job.  If that's not honest, what is? 

One of the arguments against single payer that I hear is that government reimbursement is too low.  Well all the companies I worked for paid only slightly more than Medicare (if any) on most procedures.  And that wasn't worth the extra hassles.  If you take 30% off the top, then it's significantly less.

I've found it very interesting that doctors (in general) were against national healthcare in the 90's when Clinton tried, but are for it now.  The ones I have talked to all say it's, because of all the hassles of working with insurance companies.  Billing, pre-approvals, clinical guidelines, formularies, etc.  They all felt that the reduction in overhead would more than make up for lower payments.
Yes it will reduce lots of overhead for the health system. And there are some services where the commercial payment is lower than Medicare because the payors negotiate their fee schedules as a package. So they may negotiate lower carido payments because the health system wants to capture a position in the market but they will in return pay higher on say, nerology. And this is another reason why costs differ so much from payor to payor.
We believe in my health system that the biggest benefit to single payor for us is the reduction in write offs and indigent care. Care for the uninsured.

PiobStache

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Re: What comes after the ACA?
« Reply #4967 on: November 13, 2018, 12:36:31 PM »
I'd like to know how a generic blood pressure medicine, 90 day supply, can have a Cash price of $222.19, but will only cost $6.85 after insurance negotiated discount, and would cost $10.26 if you bring in a printed GoodRX coupon.

How can the "market" for something have more than a 32X variance in price, depending on how you are billed for it?

Micro-economics at work, namely, price discrimination. 

Exflyboy

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Re: What comes after the ACA?
« Reply #4968 on: November 13, 2018, 12:49:26 PM »
I'd like to know how a generic blood pressure medicine, 90 day supply, can have a Cash price of $222.19, but will only cost $6.85 after insurance negotiated discount, and would cost $10.26 if you bring in a printed GoodRX coupon.

How can the "market" for something have more than a 32X variance in price, depending on how you are billed for it?

Micro-economics at work, namely, price discrimination.

Or "gouging".. Note that if you jack up the price of gasoline prior to the arrival of a hurricane that is somehow illegal. Yet drug providers do this all the time to desperate people who have no other choice.

Note.. so far we can still import drugs but I wonder how long before the FDA start "protecting our best interests"...

PiobStache

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Re: What comes after the ACA?
« Reply #4969 on: November 13, 2018, 03:56:49 PM »
I'd like to know how a generic blood pressure medicine, 90 day supply, can have a Cash price of $222.19, but will only cost $6.85 after insurance negotiated discount, and would cost $10.26 if you bring in a printed GoodRX coupon.

How can the "market" for something have more than a 32X variance in price, depending on how you are billed for it?

Micro-economics at work, namely, price discrimination.

Or "gouging".. Note that if you jack up the price of gasoline prior to the arrival of a hurricane that is somehow illegal. Yet drug providers do this all the time to desperate people who have no other choice.

Note.. so far we can still import drugs but I wonder how long before the FDA start "protecting our best interests"...

Those terms are not synonymous.  Gouging is short term and localized such as the example of a hurricane you gave.  Price discrimination has more to do with elasticity of demand and willingness to pay.  Of course economic definitions are rarely satisfying when one is looking to demonize.

pecunia

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Re: What comes after the ACA?
« Reply #4970 on: November 13, 2018, 06:19:44 PM »
I think a lot of you don't quite understand the health care system in this country.  Let me try to explain with a similar business that was very successful in the 1920s and 30s.  Enterprising businessmen noted an apparent need for security services and being the gentlemen they were, they filled the need.  A typical conversation with a prospective customer may go something like this:

Geez you got a good good business here Samuel.  This is a really good business and you've got steady customers and a steady cash flow.  It's a good life isn't it.  It would be a shame if something were to happen to it, Samuel.  It would be a real shame.  There are getting to be some tough people in this neighborhood.  You might of heard about what these tough guys did down to street.  It was a real bad thing. 

Well, it happens I know the hoodlums that caused that problem.  I know them quite well.  Tell you what.  You cut me in for say 17 percent and I can guarantee you they won't trouble you.

While Franklin D. Roosevelt was promoting evil socialism in the US, these enterprising businessmen were promoting capitalism.

Their descendants are keeping this great tradition alive today in the health industry.  They now obey the law and make much more money.  That's right folks, they sell health insurance.  You may have a health insurance salesman call you any day now and you will have a conversation that goes something like this:

It would be a shame if something were to happen to you sir.  It would be a real shame.  I know a fellow that lives down the street from you.  He got sick.  We had tried to sell him our protection, but he wasn't buying.    It's a real shame because now he's lost everything.  In fact, he almost lost his life.  The sickness beat him up really bad.  We have this network of doctors.  They are our people.  It's a syndicate of doctors.  Tell you what, you cut us in for say 17 percent of what you make and we can sell you some real good insurance, it's good protection.

It's just another example of people making it in the USA.  Ain't free enterprise just great?

freya

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Re: What comes after the ACA?
« Reply #4971 on: November 14, 2018, 06:12:40 AM »
Quote
Right now thereís a very vocal minority of voters who donít want the ďwrongĒ sort of people to have access to health care services and that minority happens to control the Senate. 

And are represented in the House by at least one guy from Tennessee who got 66% of the vote:

https://eu.tennessean.com/story/news/politics/2018/09/21/mark-green-government-god-health-care-marsha-blackburn/1367905002/

Quote
Government has stepped in, at least in this country, and done all the work for the church. So the person whoís in need goes ó they look to the government for the answer, not God. And I think, in that way, government has done an injustice thatís even bigger than just the entitlement ó creation of an entitlement welfare state

Single payer does not have to be an entitlement!!!  I'd be perfectly willing to pay full premiums for Medicare and continue to have a high deductible plan with HSA.  You can even give people a choice, then stand back and wait for the stampede. Medicaid can stay just exactly as it is, since it's intimately bound up in the residency training programs.  Why do politicians & reporters always try to conflate unrelated topics????  Is it sheer intellectual laziness, or is it by nefarious design?

You could also argue that private health insurance, even though it is a major driver of costs and administrative infrastructure, contributes little to health care overall.  A very large chunk of the population is on Medicaid - 25% of NY state's population, for instance.   Medicare covers another ~20-25% (the population over 65 plus people under age 65 with certain chronic conditions such as diabetes).  This represents the great majority of healthcare usage.  So private insurance is just kind of nibbling around the edges of the system anyway.  Totally absurd.  It's why I think expanding Medicare to the entire non-Medicaid population would be a piece of cake.

BeanCounter

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Re: What comes after the ACA?
« Reply #4972 on: November 14, 2018, 06:57:37 AM »
Quote
Right now thereís a very vocal minority of voters who donít want the ďwrongĒ sort of people to have access to health care services and that minority happens to control the Senate. 

And are represented in the House by at least one guy from Tennessee who got 66% of the vote:

https://eu.tennessean.com/story/news/politics/2018/09/21/mark-green-government-god-health-care-marsha-blackburn/1367905002/

Quote
Government has stepped in, at least in this country, and done all the work for the church. So the person whoís in need goes ó they look to the government for the answer, not God. And I think, in that way, government has done an injustice thatís even bigger than just the entitlement ó creation of an entitlement welfare state

Single payer does not have to be an entitlement!!!  I'd be perfectly willing to pay full premiums for Medicare and continue to have a high deductible plan with HSA.  You can even give people a choice, then stand back and wait for the stampede. Medicaid can stay just exactly as it is, since it's intimately bound up in the residency training programs.  Why do politicians & reporters always try to conflate unrelated topics????  Is it sheer intellectual laziness, or is it by nefarious design?

You could also argue that private health insurance, even though it is a major driver of costs and administrative infrastructure, contributes little to health care overall.  A very large chunk of the population is on Medicaid - 25% of NY state's population, for instance.   Medicare covers another ~20-25% (the population over 65 plus people under age 65 with certain chronic conditions such as diabetes).  This represents the great majority of healthcare usage.  So private insurance is just kind of nibbling around the edges of the system anyway.  Totally absurd.  It's why I think expanding Medicare to the entire non-Medicaid population would be a piece of cake.
It would be a piece of cake. And it would be good for Medicare because you would have lots of healthy people paying into the system like myself, who only go for their annual check up and maybe one office visit every other year for illness.
Unfortunately private insurance has lots of lobbyists to keep this from happening because their jobs depend on it. Oh, and investors. I had great stock options when I worked for a major payor.
Guess who pays for all of this.

PiobStache

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Re: What comes after the ACA?
« Reply #4973 on: November 14, 2018, 02:16:40 PM »
It would be a piece of cake. And it would be good for Medicare because you would have lots of healthy people paying into the system like myself, who only go for their annual check up and maybe one office visit every other year for illness.

All those healthy people like yourself actually are already paying into the Medicare system. 

Bucksandreds

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Re: What comes after the ACA?
« Reply #4974 on: November 14, 2018, 03:13:32 PM »
It would be a piece of cake. And it would be good for Medicare because you would have lots of healthy people paying into the system like myself, who only go for their annual check up and maybe one office visit every other year for illness.

All those healthy people like yourself actually are already paying into the Medicare system.

Thatís prepaying for care when theyíre elderly. The poster is talking about also paying for current care.

PiobStache

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Re: What comes after the ACA?
« Reply #4975 on: November 14, 2018, 03:28:50 PM »
All those healthy people like yourself actually are already paying into the Medicare system.

Thatís prepaying for care when theyíre elderly. The poster is talking about also paying for current care.

I'm afraid that's not an accurate characterization as the unfunded liability for Medicare is in the trillions.

BeanCounter

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Re: What comes after the ACA?
« Reply #4976 on: November 14, 2018, 03:47:12 PM »
It would be a piece of cake. And it would be good for Medicare because you would have lots of healthy people paying into the system like myself, who only go for their annual check up and maybe one office visit every other year for illness.

All those healthy people like yourself actually are already paying into the Medicare system.
Correct, but Iím also paying for private insurance premiums (along with my employer) and everything I donít use either goes to fund the negative risk pool from the payers members or to the pastors bottom line. We would all be better of if healthy plan members like were paying all premiums into Medicare. This creating a larger risk pool.

Bucksandreds

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Re: What comes after the ACA?
« Reply #4977 on: November 14, 2018, 04:33:01 PM »
All those healthy people like yourself actually are already paying into the Medicare system.

Thatís prepaying for care when theyíre elderly. The poster is talking about also paying for current care.

I'm afraid that's not an accurate characterization as the unfunded liability for Medicare is in the trillions.

Of course itís unfunded. It requires constant influxes of cash from future generations. Thatís how it works. The percentage of income paid may need to be raised but acting like itís going to go away is wishful thinking on your part.

seattlecyclone

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Re: What comes after the ACA?
« Reply #4978 on: November 14, 2018, 08:58:57 PM »
All those healthy people like yourself actually are already paying into the Medicare system.

Thatís prepaying for care when theyíre elderly. The poster is talking about also paying for current care.

I'm afraid that's not an accurate characterization as the unfunded liability for Medicare is in the trillions.

Of course itís unfunded. It requires constant influxes of cash from future generations. Thatís how it works. The percentage of income paid may need to be raised but acting like itís going to go away is wishful thinking on your part.


Just because we expect a program to continue doesn't mean it's accurate to say the taxes you're paying today are actually a prepayment for future services to be received. Current workers pay for current retirees. That's how it's always worked and how we expect it to work going forward.

PiobStache

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Re: What comes after the ACA?
« Reply #4979 on: November 15, 2018, 10:16:01 AM »
Of course itís unfunded. It requires constant influxes of cash from future generations. Thatís how it works. The percentage of income paid may need to be raised but acting like itís going to go away is wishful thinking on your part.

If it's unfunded then how can you claim current contributors are "pre-paying?"  Something cannot be both unfunded and pre-paid simultaneously.  Also, please quote where I "acted" like I thought it was going away.

Bucksandreds

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Re: What comes after the ACA?
« Reply #4980 on: November 15, 2018, 03:39:28 PM »
Of course itís unfunded. It requires constant influxes of cash from future generations. Thatís how it works. The percentage of income paid may need to be raised but acting like itís going to go away is wishful thinking on your part.

If it's unfunded then how can you claim current contributors are "pre-paying?"  Something cannot be both unfunded and pre-paid simultaneously.  Also, please quote where I "acted" like I thought it was going away.

Collins.com dictionary.

A prepayment is a payment that you make before you receive goods or services, or before a debt is due

Prepayment doesnt mean that the money is set aside to be redistributed directly to you.  Iím not the one who started arguing semantics, either.

DreamFIRE

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Re: What comes after the ACA?
« Reply #4981 on: November 15, 2018, 06:43:36 PM »
Medicare is expensive for seniors, and it underpays healthcare facilities for services.

Medicare doesn't mean free, even after you retire.  You can't even get part A for free if you haven't paid into the system for at least 40 quarters.  If you haven't, you have to pay for Part A.  And if you want decent coverage, you're looking at part B, D, and a supplemental, which everyone has to pay for while being covered.  Someone earlier in this thread mentioned that they were paying about $1000/mo total for Medicare, not a pre-payment while working, but while actually being on Medicare, that on top of having worked to qualify for Part A.

Exflyboy

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Re: What comes after the ACA?
« Reply #4982 on: November 15, 2018, 06:55:46 PM »
Yup.. Or just take the risk for the 20% unlimited co-pay.

Some cancer treatments (even if they approve them) are running $1M/year.. Not advisable.

PiobStache

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Re: What comes after the ACA?
« Reply #4983 on: November 16, 2018, 09:35:54 AM »
Collins.com dictionary.

A prepayment is a payment that you make before you receive goods or services, or before a debt is due

Prepayment doesnt mean that the money is set aside to be redistributed directly to you.  Iím not the one who started arguing semantics, either.

It is assumed the prepayment actually pays for the good or service to be delivered.  As the person that paid Medicare tax for 40 years on annual income of $1 million will get the exact same service the person that paid in for 10 years on poverty wages...it's clearly not a "prepayment" in any meaningful sense. 

It's a tax that covers a welfare program just like Social Security.


Scandium

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Re: What comes after the ACA?
« Reply #4984 on: November 16, 2018, 10:08:41 AM »
Quote
Right now thereís a very vocal minority of voters who donít want the ďwrongĒ sort of people to have access to health care services and that minority happens to control the Senate. 

And are represented in the House by at least one guy from Tennessee who got 66% of the vote:

https://eu.tennessean.com/story/news/politics/2018/09/21/mark-green-government-god-health-care-marsha-blackburn/1367905002/

Quote
Government has stepped in, at least in this country, and done all the work for the church. So the person whoís in need goes ó they look to the government for the answer, not God. And I think, in that way, government has done an injustice thatís even bigger than just the entitlement ó creation of an entitlement welfare state

Also:
"On his campaign site, Green said he supports free-market based approaches to health care."

I don't understand how he thinks this would work. As I see it the only way medical care can work on a "free-market based approach" is if you are ok with letting poor and/or sick people die. If the market is free nobody would insure anyone with an illness, or anyone over 50-ish years old. So the people who needed the care the most could not get coverage anywhere, and the people who need it the least are the (only?) people the insurance companies want as customers. The incentives are opposite of what you want. How do you sell insurance for something people are eventually 99% sure to use, and at great cost?? Yes young men pay more for car insurance since they are more likely to use it, but most of them don't crash. Practically 100% of people over 60 will use medical care for 5-6 figure sums within a decade, how do you price that? $30k/year premiums? Rising to $50k when you're 70?

PiobStache

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Re: What comes after the ACA?
« Reply #4985 on: November 16, 2018, 10:33:59 AM »
I don't understand how he thinks this would work. As I see it the only way medical care can work on a "free-market based approach" is if you are ok with letting poor and/or sick people die. If the market is free nobody would insure anyone with an illness, or anyone over 50-ish years old. So the people who needed the care the most could not get coverage anywhere, and the people who need it the least are the (only?) people the insurance companies want as customers. The incentives are opposite of what you want. How do you sell insurance for something people are eventually 99% sure to use, and at great cost?? Yes young men pay more for car insurance since they are more likely to use it, but most of them don't crash. Practically 100% of people over 60 will use medical care for 5-6 figure sums within a decade, how do you price that? $30k/year premiums? Rising to $50k when you're 70?

This would be why risk pools were invented. 

Scandium

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Re: What comes after the ACA?
« Reply #4986 on: November 16, 2018, 11:24:38 AM »
I don't understand how he thinks this would work. As I see it the only way medical care can work on a "free-market based approach" is if you are ok with letting poor and/or sick people die. If the market is free nobody would insure anyone with an illness, or anyone over 50-ish years old. So the people who needed the care the most could not get coverage anywhere, and the people who need it the least are the (only?) people the insurance companies want as customers. The incentives are opposite of what you want. How do you sell insurance for something people are eventually 99% sure to use, and at great cost?? Yes young men pay more for car insurance since they are more likely to use it, but most of them don't crash. Practically 100% of people over 60 will use medical care for 5-6 figure sums within a decade, how do you price that? $30k/year premiums? Rising to $50k when you're 70?

This would be why risk pools were invented.

please explain. As anyone over 60 is basically a 100% risk, how do you spread that out? Market-wise the best is just to leave them out.

ysette9

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Re: What comes after the ACA?
« Reply #4987 on: November 16, 2018, 10:30:38 PM »
Well with life insurance (we are all guaranteed to die) you spread the risk by forcing people to buy in far in advance of the estimated time you will need the policy benefit. That forces a “risk pool” in the sense that at any given time your policy holders should be a good mix of young and old, sick and healthy, more and less likely to die and collect on the policy. The healthcare equivalent of this is making everyone buy health insurance or providing universal coverage in some mechanism.

EnjoyIt

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Re: What comes after the ACA?
« Reply #4988 on: November 16, 2018, 11:07:17 PM »
I don't understand how he thinks this would work. As I see it the only way medical care can work on a "free-market based approach" is if you are ok with letting poor and/or sick people die. If the market is free nobody would insure anyone with an illness, or anyone over 50-ish years old. So the people who needed the care the most could not get coverage anywhere, and the people who need it the least are the (only?) people the insurance companies want as customers. The incentives are opposite of what you want. How do you sell insurance for something people are eventually 99% sure to use, and at great cost?? Yes young men pay more for car insurance since they are more likely to use it, but most of them don't crash. Practically 100% of people over 60 will use medical care for 5-6 figure sums within a decade, how do you price that? $30k/year premiums? Rising to $50k when you're 70?

This would be why risk pools were invented.

You just described one of the big problems in healthcare today. Healthcare and insurance are not synonsymous. Actually most people use health insurance but not as insurance but as a payment vehicle for regular and common healthcare needs.

Insurance should exist for catastrophical events that one needs financial insurance against. How much regular non-catstrophic health care costs and how it will be payed for by those who canít afford any of it is a whole other discussion. If we focused on that instead of insurance we would already be ahead of the game.

Right now insurance is nothing more than a bookie taking his cut off every transaction. Medicare and Medicaid are no different they just donít need to have profits in their process but they still need their cut to pay for said process.

Bucksandreds

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Re: What comes after the ACA?
« Reply #4989 on: November 17, 2018, 05:19:09 AM »
Collins.com dictionary.

A prepayment is a payment that you make before you receive goods or services, or before a debt is due

Prepayment doesnt mean that the money is set aside to be redistributed directly to you.  Iím not the one who started arguing semantics, either.

It is assumed the prepayment actually pays for the good or service to be delivered.  As the person that paid Medicare tax for 40 years on annual income of $1 million will get the exact same service the person that paid in for 10 years on poverty wages...it's clearly not a "prepayment" in any meaningful sense. 

It's a tax that covers a welfare program just like Social Security.

You or your spouse has to pay into Medicare for 10 years to qualify.  Nothing about the definition of prepayment excludes Medicare from that.  Donít try to be semantic on me if youíre wrong.

freya

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Re: What comes after the ACA?
« Reply #4990 on: November 17, 2018, 09:37:26 AM »
"On his campaign site, Green said he supports free-market based approaches to health care."

I don't understand how he thinks this would work. As I see it the only way medical care can work on a "free-market based approach" is if you are ok with letting poor and/or sick people die.

YES.  You have to spread around risk as widely as possible, because we are ALL at risk.  And the risk increases greatly as you get older.

Privatizing Medicare could theoretically work if insurance premiums for everyone increased by the amount paid into the Medicare tax.  However, Paul Ryan and his buddies are forgetting that private insurance's overhead is about 30% higher than it is for Medicare - and Medicare currently does most of the heavy lifting in health care reimbursement.   We as a country simply can't afford that.  Of course, the private insurance lobby must be driving this whole idea, because obviously they'd make out like bandits.  There's also the magical "out of network" problem, which could wipe out your nest egg faster than you can blink.  What do you do at age 70+ when that happens??



BeanCounter

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Re: What comes after the ACA?
« Reply #4991 on: November 17, 2018, 10:56:26 AM »
"On his campaign site, Green said he supports free-market based approaches to health care."

I don't understand how he thinks this would work. As I see it the only way medical care can work on a "free-market based approach" is if you are ok with letting poor and/or sick people die.

YES.  You have to spread around risk as widely as possible, because we are ALL at risk.  And the risk increases greatly as you get older.

Privatizing Medicare could theoretically work if insurance premiums for everyone increased by the amount paid into the Medicare tax.  However, Paul Ryan and his buddies are forgetting that private insurance's overhead is about 30% higher than it is for Medicare - and Medicare currently does most of the heavy lifting in health care reimbursement.   We as a country simply can't afford that.  Of course, the private insurance lobby must be driving this whole idea, because obviously they'd make out like bandits.  There's also the magical "out of network" problem, which could wipe out your nest egg faster than you can blink.  What do you do at age 70+ when that happens??
We have privatized Medicare, itís called Medicare Advantage. When you sign up for an MA plan you have elected to transfer your risk (for that contract year) from Medicare to the payors MA plan. The payor is betting on one of two things happening, either you will be a healthy member and the premiums they receive from CMS will be higher than your utilization or they will be able to ďmanage your careĒ (aka manage your SPEND) to a profitable level.

freya

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Re: What comes after the ACA?
« Reply #4992 on: November 18, 2018, 08:36:53 AM »
"On his campaign site, Green said he supports free-market based approaches to health care."

I don't understand how he thinks this would work. As I see it the only way medical care can work on a "free-market based approach" is if you are ok with letting poor and/or sick people die.

YES.  You have to spread around risk as widely as possible, because we are ALL at risk.  And the risk increases greatly as you get older.

Privatizing Medicare could theoretically work if insurance premiums for everyone increased by the amount paid into the Medicare tax.  However, Paul Ryan and his buddies are forgetting that private insurance's overhead is about 30% higher than it is for Medicare - and Medicare currently does most of the heavy lifting in health care reimbursement.   We as a country simply can't afford that.  Of course, the private insurance lobby must be driving this whole idea, because obviously they'd make out like bandits.  There's also the magical "out of network" problem, which could wipe out your nest egg faster than you can blink.  What do you do at age 70+ when that happens??
We have privatized Medicare, itís called Medicare Advantage. When you sign up for an MA plan you have elected to transfer your risk (for that contract year) from Medicare to the payors MA plan. The payor is betting on one of two things happening, either you will be a healthy member and the premiums they receive from CMS will be higher than your utilization or they will be able to ďmanage your careĒ (aka manage your SPEND) to a profitable level.

Well, sort of.  Advantage plans work fine for people who are relatively healthy, but that means that once again, private insurance is skimming off the most profitable patients.  They have to get their extra 30% in overhead and profit from somewhere.  I don't think this model would work if these companies had to cover everyone, which is essentially what Paul Ryan is proposing - at least not without big premium increases, big copays/deductibles/out of network costs, and a lot of coverage denials.  I guess maybe that's the idea.

pmac

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Re: What comes after the ACA?
« Reply #4993 on: November 25, 2018, 02:05:48 AM »
Looking up option for my wife and I on Healthcare.gov

Pretty much no options for plans that are HSA compliant, so I looked on Blue Cross Blue Shield (Texas) website and they have 2 different plans that are HSA compliant, unfortunately both are around $700/month in premiums. These 2 policies are also not ACA compliant, but they still offer mental health and substance abuse coverage.

Is there anyway to get non-ACA compliant coverage, that is HSA compliant, that doesn't cover mental health and substance abuse? Seems like if it's non-ACA compliant, then it doesn't need to cover that. Also has no lifetime maximum, I remember getting insurance pre-Obamacare and you could get a cheaper health insurance policy by getting a $1 million or $2 million lifetime maximum.

Thanks!

pecunia

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Re: What comes after the ACA?
« Reply #4994 on: November 25, 2018, 06:33:40 AM »
In the 100 or so pages of this discussion, I'm quite sure this information has been promulgated somewhere, but I'll plop it in just the same.  I was complaining to a sibling about the high cost of insurance and the limited options and wrote a few facts up.  The summary is that our government is already paying a lot towards health care.  It made me think eliminating insurance companies and paying more taxes to replace insurance companies would not be such a bad thing.

Obamacare (ACA) subsidizes insurance.

That subsidy may be why insurance is so high.  Insurance companies see free money guaranteed by Uncle Sam.  I'd rather pay it to Uncle Sam and have them do the health care thing.  It would take a lot of greed out and almost assuredly a lot of waste.

You may find this interesting unless I have already tuned you out:

The United States spends more on health care than any other country in the world, and a large share of that spending comes from the federal government.

"In 2017, the United States spent about $3.5 trillion, or 18 percent of GDP, on health expenditures Ė more than twice the average among developed countries.

Of that $3.5 trillion, $1.5 trillion, is directly or indirectly financed by the federal government. In other words, the federal government dedicates resources of nearly 8 percent of the economy toward health care. By 2028, we estimate these costs will rise to $2.9 trillion, or 9.7 percent of the economy. Over time, these costs will continue to grow and consume an increasing share of federal resources."

So if they spent 1.5 trillion, how much per person?

"The current population of the United States of America is 327,678,262 as of Saturday, November 24, 2018, based on the latest United Nations estimates. the United States population is equivalent to 4.28% of the total world population."

Amount spent by the government / number of people => 1,500,000,000,000 / 327,678,262 = $4,577.66 / person

Remember - This is government only no insurance.

How about Canada?

"Total health spending in Canada is projected to reach $242 billion in 2017, with growth of around 3.9%. This will represent 11.5% of Canada's gross domestic product and equal $6,604 per Canadian. Health spending has trended upward since 1975, both in current dollars and in 1997 constant dollars."

How about England?

"In pounds per head, that's £2,892 on healthcare for every person in the UK and £7,617 per person in the US."

$10.00 is 7.8 lbs.  So 2,892 lbs X 10/7.8 = $3,707 per person     Hey!  The United States government already spends more than that per person.

How about France?

Well $4600 per person in 2016.

You get the idea.  The government is already spending enough to take care of most of the people.  Somewhere it is being siphoned off.  Hmmmmm, could it be insurance companies?

Next time you hear old Bernie talk about it, don't call him a crackpot.  What a bizarre world.

Note to pmac - good Luck with that.  Texas gives me the impression that they are one of the worst states for their implementation of the ACA.

This situation is obviously unsustainable and is certain to change in the next few years.  It affects every one of us.

freya

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Re: What comes after the ACA?
« Reply #4995 on: November 25, 2018, 07:50:43 AM »
Thanks for those calculations & numbers, pecunia!

In addition to the federal government spending, you have to add in Medicaid spending - a large portion of that is financed by state and local taxes.

You're absolutely right about money being siphoned off - here are some of the siphoners:

- The ridiculously complex billing system (see my prior posts)
- Pharmaceutical companies - we'd save a few hundred billion just by adopting the drug prices negotiated by Canada
- Perverse incentives in the reimbursement structure
- Overhead imposed by insurance requirements (mostly by the private insurers), Medicare-imposed documentation requirements, the EHR requirement, and the "PQRI" and other miscellaneous burdens that really, really add up.
- Overuse and over-hyping of preventive care
- Malpractice lawsuits.  I would favor a system where a state medical board first determines if medical wrongdoing occurred, THEN victims can sue for damages based on that determination.
- Professional patients.  There will always be people gaming the system, but in the US it's way too easy to get SSI and endless treatments for nonexistent problems.  Other countries handle this much better.

pmac

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Re: What comes after the ACA?
« Reply #4996 on: November 25, 2018, 08:39:17 AM »
Pecunia
Good points. This is the same reason College Education is so expensive. The more the government subsidizes something, the more the cost goes up.

I remember pre-ACA  I could get an HSA compliant plan with Blue Cross Blue Shield of Texas for somewhere around $120 month. Obviously this coverage did not include mental health or substance abuse, and also had a $2 million dollar annual limit, but it covered everything I wanted.



Now, going through the BCBSTX website they have nothing I want that is HSA compliant, non-ACA. I don't want a plan that covers mental health or substance abuse treatment, and I don't mind getting a plan that has a $2 million or $3 million maximum.




Also,
What's preventing healthy young people going on the short term plans, then if a catastrophic event happens going back on the Obamacare since it covers pre-existing conditions?

This seems like the best idea to avoid the crazy high ACA premiums...

sol

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Re: What comes after the ACA?
« Reply #4997 on: November 25, 2018, 09:12:02 AM »
This is the same reason College Education is so expensive. The more the government subsidizes something, the more the cost goes up.

Well that seems like only half of the story.  The government subsidizes the power grid and those costs just keep going down.  It subsidizes farmers in order to "stabilize" prices and food is cheaper than ever.  Meanwhile Netflix stock is up roughly 40% in the past year and it receives no subsidies at all.  I'm not sure that government subsidies alone are what's driving up the cost of healthcare.  It's almost like there are other market forces at play or something.

Quote
I remember pre-ACA  I could get an HSA compliant plan with Blue Cross Blue Shield of Texas for somewhere around $120 month.

The entire health insurance market was different back then.  Insurers could offer cheaper plans because they could rescind your coverage as soon as you got sick or injured, so they didn't really have to pay for anything if they didn't want to.  They could exclude things like pregnancy costs or sport injuries pretty much at will, and they could deny coverage to anyone for any reason if they didn't think you were going to be profitable.  Remember that millions of Americans couldn't get health insurance AT ALL, at any price, before the affordable care act came along.  If you were already sick, our compassionate conservative national policy was that you should go fuck yourself.  Die in a gutter, please.  So yea, certain types of plans were cheaper.

Quote
this coverage did not include mental health or substance abuse, and also had a $2 million dollar annual limit, but it covered everything I wanted.

Part of the ACA's intent was to protect people from themselves.  Just because a 25 year old customer didn't want ______ coverage didn't mean that they weren't going to have to pay for ______.  The mandated minimum coverage rules were put in place to protect everyone, customers and insurers, from having to fight over what was covered and what wasn't. 

Some people genuinely didn't want health insurance at all.  Or more accurately, they didn't want to pay for health insurance, knowing that they would still receive medical care if necessary without having to pay for it. We call those people freeloaders.  Even if you didn't want coverage for methadone treatment, that treatment was still going to be available to you whether you want to pay for it or not, because as a society we have discovered that methadone treatment is something that benefits everyone.  By trying to avoid paying for a service you were already being insured against, you were taking on a tiny part of the freeloader mantle yourself.  Mandatory minimum coverage standards were designed to solve this problem.

Quote
What's preventing healthy young people going on the short term plans, then if a catastrophic event happens going back on the Obamacare since it covers pre-existing conditions?

Previously?  The individual mandate was supposed to address this problem, but Republicans repealed it as part of their ongoing efforts to undermine American healthcare.


bacchi

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Re: What comes after the ACA?
« Reply #4998 on: November 25, 2018, 09:30:25 AM »
I remember pre-ACA  I could get an HSA compliant plan with Blue Cross Blue Shield of Texas for somewhere around $120 month.

The entire health insurance market was different back then.  Insurers could offer cheaper plans because they could rescind your coverage as soon as you got sick or injured, so they didn't really have to pay for anything if they didn't want to.  They could exclude things like pregnancy costs or sport injuries pretty much at will, and they could deny coverage to anyone for any reason if they didn't think you were going to be profitable.  Remember that millions of Americans couldn't get health insurance AT ALL, at any price, before the affordable care act came along.  If you were already sick, our compassionate conservative national policy was that you should go fuck yourself.  Die in a gutter, please.  So yea, certain types of plans were cheaper.

Insurers also used the raise-the-premiums gambit in order to shake off any losses.

1) Every year, create a new plan very similar to every other plan currently in place. It's as easy as bumping up the deductible by $25.
2) Raise the premiums of existing plans. This shakes off the healthy that can qualify for one of the new, slightly modified, plans.
3) Anyone who sticks around is either too busy to find another plan or is worried about qualifying.
4) Repeat until the premiums for the original plan are extremely high and even the sick have to leave for the state high risk pool.

In essence, the premiums were low exactly BECAUSE the insurers maintained a healthy clientele.

pmac

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Re: What comes after the ACA?
« Reply #4999 on: November 25, 2018, 09:43:07 AM »
I want to get back to the practical question I had.

How do I find a good health insurance policy that is HSA compliant, but not ACA compliant, that doesn't cover mental health or substance abuse, and allows for an annual maximum of $2,000,000?

Looking on Blue Cross Blue Shield Texas website I can't find this.

Has anybody had luck finding non-ACA plans with one of the big insurance groups (United, Blue Cross, Aetna, Kaiser)?

Paying $1,000/month in premiums for ACA compliant plans with deductibles of $6,000/person is absolutely crazy.




More importantly, will they release these plans after the December 15 deadline for those looking for ACA plans? Maybe the big guys are hoping that they will get everybody on the more expensive ACA plans before releasing more non-ACA plans?

Thanks!